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Sleep-related breathing disorders have been associated with increased perioperative morbidity and mortality. The respective patients are at risk during two independent periods. Besides an early period, characterised by the influence of anaesthetics, patients are at risk also during a late period, which is characterised by nocturnal desaturation and disturbances of the cardiovascular system, caused by interference with the sleep architecture, especially of the REM sleep. To assure a safe perioperative management, a close monitoring (O2 saturation and pCO2) and the option for non-invasive ventilation have to be guaranteed.

Background: Primary management of tonsillar hyperplasia in children is tonsillectomy. Recent data from clinical case-series are clearly in support of the hypothesis that tonsillotomy with the CO2-laser seems to be effective and is noted to have less postoperative bleeding and less pain as compared to tonsillectomy. For the first time we used a monopolar argon-supported needle for tonsillotomy in the following study., Methods: Fifty patients (age: 4.58 years; SD +/- 2.33) with benign tonsillar hyperplasia were recruited. For tonsillotomy we used the monopolar argon-supported needle. The outcome measures were postoperative pain, capability of oral intake, consumption of analgesics and postoperative bleeding., Results: No postoperative bleeding occurred. Post-operative pain hardly occurred and could easily be controlled. The third postoperative day analgesics intake was under one portion per day (mean: 0.91; SD +/- 1.26). Capability of oral intake and swallowing was normal on the seventh postoperative day., Conclusion: It was concluded that tonsillotomy, using the monopolar argon-supported needle, is a valid treatment for benign tonsillar hyperplasia in children, which can be performed with slight post-operative pain and a low risk for postoperative bleeding. It offers good dissection and haemostasis abilities. Compared to the CO2-laser the monopolar argon-supported needle does not require any laser safety precautions.

Laser-assisted surgery is a valid option for the treatment of respiratory sleep disorders and complements established therapies. Laser-surgery of the inferior turbinates can improve nasal obstruction and amend or eliminate primary snoring. LAUP is as well an ambulant therapeutic method for snoring, but it is leading to strong post-operative pain and should exclusively be applied to patients with small tonsils or who already underwent tonsillectomy. OSAS can be worsened by LAUP and should therefore be excluded before the operation. In childhood OSAS laser tonsillotomy leads to a distinct improvement of sleep-disordered breathing with normalisation of the sleeping profile; it is less painful than tonsillectomy and a part of the tonsil is left to continue to exercise its function in the immune system.

Background: The present study was undertaken in an effort to assess the use and the efficacy of an innovative radiofrequency system (RaVoR, Select-Sutter, Freiburg i. Br.) and the bipolar electrodes conceived by the author for the treatment of habitual, disruptive snoring. The author's own surgical method takes into account a number of published retrospective studies on radiofrequency application in the treatment of snoring and is based on important anatomical, physiopathological and histological knowledge., Patients and Methods: Thirty-one patients diagnosed with primary snoring and five patients with associated sleep apnea syndrome (SAS) were treated according to the method and with the RaVoR system in the past three years. The intensity as well as the snoring density was assessed on a numeric analogue scale (NAS; ranging from 0 = "patient doesn't snore anymore" to 4 = "patient continues to snore as before"), which was filled out by the partner preoperatively and postoperatively after 6 months and 2 years., Results: Snoring was reduced in 31 (86 %) patients (NAS

Introduction: Obstructive sleep apnea (OSA) is characterized by nocturnal collapsing of the upper airways. Nasal continuous positive airway pressure (nCPAP) ventilation is the gold standard in the treatment of obstructive sleep apnea syndrome (OSAS). Long-term compliance rates do not exceed more than 60 to 70%. Alternative multi-level surgeries are of interest, combining procedures at the level of the base of tongue and the soft palate in order to stabilize the airway. Preliminary results suggested the hyoid suspension as one part of the multi-level surgery concept to be of high effectiveness. Therefore this study investigated the outcome of the hyoid suspension and compared it with the CPAP therapy., Methods: Between March 2001 and February 2003, 66 patients with OSA were treated with a hyoid suspension in combination with surgeries at the base of tongue, the soft palate or the nose (always performed by the same surgeon). All patients underwent a pre- and postoperative polysomnography in the sleep lab. Daytime sleepiness was assessed using the Epworth Sleepiness Scale (ESS). Mean age was 52,1 years, the mean body mass index (BMI) was 28,04 kg/m(2)., Results: The mean apnea-hypopnea-index (AHI) was 38,9121,10/h before operation and 19,25+/-19,64/h after operation (p<0,0001). More statistically significant changes were found for the arousal index, the oxygen saturation and the ESS (p<0,05). After surgery 57,6% of the subjects (38/66) were regarded as cured (reduction of AHI > or =50% and below 15/h). Another 21,2% (14/66) improved (reduction of AHI >20%). Altogether 78,8% of the patients were counted as responders., Conclusion: Multi-level surgeries based on the hyoid suspension show the effectiveness of this concept. This surgical strategy could be equal to the CPAP mask, especially in cases of CPAP intolerance.

Background: Thrombosis of the internal jugular vein is a rare and critical disease which can also be a complication of a benign oropharyngeal infection (Lemierre syndrome)., Patient: A 62 year old patient underwent septomplasty, endonasal turbinectomy, paranasal sinus surgery and tonsillectomy. The postoperative course was uneventful until the 11th post operative day when the patient reported a painful swelling on the right side of the neck. Color Doppler ultrasonography demonstrated thrombosis of the right internal jugular vein and a CT-scan showed a right sided cervical phlegmonous soft tissue inflammation originating from the right oropharynx. Despite immediate intravenous antibiotic treatment, the patient developed a septic infection and resection of the jugular vein was conducted., Conclusion: Lemierre syndrome is a rare condition which may also follow tonsillectomy. Under septic conditions, the resection of the internal jugular vein has to be performed to avoid serious complications.

Background: Cheyne-Stokes respiration is characterized by recurrent phases of central apneas during sleep alternating with a crescendo-decrescendo hyperventilation. This abnormal respiratory pattern is often observed in patients with severe congestive heart failure and associated with fragmentation of sleep, excessive daytime sleepiness, and a relatively high mortality. Increased peripheral and central chemosensitivity, prolonged circulation time, and reduced blood gas buffering capacity are the major factors contributing to the pathology. However, the exact pathophysiologic mechanisms are not clear yet. Respiratory stimulants, oxygen and continuous or bilevel positive airway pressure (CPAP or BiPAP) might reduce the severity of Cheyne-Stokes respiration but have little effect on daytime sleepiness and cardiac function. There is only limited data supporting the assumption that intensive heart failure therapy has an effect on Cheyne-Stokes respiration., Case Report: A 55-year-old male patient with dilative cardiomyopathy (NYHA IV) suffered excessive daytime sleepiness (Epworth Sleepiness Scale: 24 points). The patient was a heavy snorer with a normal body mass index. Treatment was initiated including ACE-inhibitors, beta-receptor blockers, diuretics and digoxin. The patient underwent sleep analysis with a Somno-Check system which demonstrated Cheyne-Stokes breathing (Respiratory Disturbance Index RDI: 40/h, lowest desaturation 76%) and body position dependent snoring. Oxygen therapy (21/min) had no effect on daytime sleepiness. Due to the cardiac condition, the patient was accepted for heart transplantation. Three weeks after transplantation sleep analysis was repeated and demonstrated a lack of evidence for periodic breathing (RDI 1/h, no desaturations below 90%), while snoring remained unchanged. Daytime sleepiness improved significantly (Epworth Sleepiness Scale: 6 points). Three weeks after normalizing left ventricular function a complete recovery from severe Cheyne-Stokes respiration was observed., Conclusion: Adequate therapy of the underlying cause of Cheyne-Stokes breathing such as end-stage congestive heart failure might sufficiently abolish any breathing abnormalities.

65 children were analysed prospectively before and after adeno-tonsillectomy to determine the incidence of upper airway infections, snoring and nocturnal obstructive symptoms. The weight and height percentiles were also determined before and after adeno-tonsillectomy. The Oxygen Desaturation Index (ODI) was measured in 27 children suspected of having a sleep apnea syndrome. In six of these children polysomnographic studies were carried out. A statistically significant reduction (p < 0,005) of upper airway infections could be seen six to twelve months after adeno-tonsillectomy. In 25 children (38%), we observed a postoperative weight gain and in eight cases (12%) a height gain. The obstructive symptoms, especially snoring and respiratory apneas, disappeared or were significantly reduced in 90% of the cases after adeno-tonsillectomy. All preoperatively pathological ODI and AHI normalised after the operation (p < 0,005).

Before the invention of CPAP therapy, the only effective surgical treatment for obstructive sleep apnea syndrome was tracheotomy. Now, surgical approaches mainly focus on two anatomical sites. Each procedure influences either the retropalatal or retrolingual portion of the pharynx. They might be applied individually, synchronously with other procedures, or sequentially with other therapeutic devices. Common methods of velar surgery include uvulopalatopharyngoplasty (UPPP), Laser-assisted uvuloplasty (LAUP), radiofrequency or uvulaflap. These techniques are indicated mainly in patients with mild OSAS. Other procedures focus on the posterior airway space (PAS), including operations that reduce the volume of the tongue or base of tongue. In selected patients, an enlargement of the retrolingual airway is gained by osteosynthetic techniques. Improvement of the nasal airway passage is gained by performing a septoplasty and/or conchotomy. In this paper, the different methods and their indications for surgical therapy will be explained and the results are summarized.

Background: Nasal obstruction may be a causative factor in the etiology of obstructive sleep apnea. No studies were found that dealt with the role of nasal polyps in sleep apnea., Method: Two male patients, 69 and 44 years old, were examined in our clinic because of nasal polyps occluding the nasal cavity. Their main complaint was nasal breathing obstruction with hyposmia. The clinical history revealed snoring but neither apnea nor daytime sleepiness was reported. Both patients underwent full nocturnal 12-channel polysomnography (PSG) prior to endonasal sinus surgery. PSG and nasal endoscopy were performed 3 months postoperatively., Result: The patients showed an increased apnea hypopnea index (AHI) from 21.1 to 76.6 and 7 to 38.8 respectively. Excessive daytime sleepiness (EDS) appeared and relative duration of REM sleep decreased. Nasal CPAP therapy was recommended., Conclusion: Although patients felt relieved after surgery since their nasal breathing problem was solved, the results with respect to AHI, EDS, and sleep pattern were unexpected. Perhaps these findings can be explained by surgical alteration of nasal receptors or by a postoperative switch from oral to nasal nocturnal breathing.

Diagnosis and therapy of obstructive sleep-related breathing disturbances SRBD in adults may not be applied without hesitation to children. SRBD in newborn and infants are often due to craniofacial disturbances (Pierre Robin syndrome, Goldenhars syndrome etc.), obesity is of minor importance. More than 30 infants with SRBD and craniofacial changes have been diagnosed and successfully treated over a 2-year period. Conservative therapy starts immediately after birth. The first step in newborn with Pierre Robin syndrome, for instance, is prone position for protrusion of tongue and mandible and mandibular growth stimulation. Intermediate nightly nasopharyngeal tubes are an alternative to nCPAP-/BiPAP treatment. Conventional orthopaedic/orthodontic treatment should not be neglected, even if it takes years to become effective. Surgical therapies are able to support, sometimes to replace or at least to shorten conservative methods. In rare cases when prone position in combination with palatal plates in cases of Robin syndrome, for instance, are not fully effective, mandibular extension is indicated. Aplasia or defects demand adequate surgical reconstruction, even if this does not necessarily mean abolishment of SRBD. In contrast to adults adenotonsillectomy is highly effective in infants and does not only reduce SRBD, but also improves nasal breathing and thus positively influences facial growth. A relatively new method is gradual mandibular distraction osteogenesis according to Ilizarov, which also enhances soft tissue growth. Maxillary and mandibular advancement osteotomies should not be considered before the termination of facial growth. Thanks to this refined treatment concept we were able to avoid tracheotomies in children during the past few years.

In order to improve the outcome of surgical treatment for obstructive sleep apnea syndrome certain reports have claimed to identify the site of obstruction in the upper airway. One of the various methods available for topodiagnosis is manometry using intraesophageal and intrapharyngeal pressure probes. In the present literature the surgical success rate for patients undergoing Uvulopalatoplasty (UPP) as treatment for retropalatal obstructions is approximately 50%. For patients with other sites of obstruction the success rate is below 10%. The aim of this study was to evaluate the different theories explaining the still low outcome of UPPP in patients with only retropalatal collapse. Findings showed that measurements within different sleep stages and at different pharyngeal activities during sleep can lead to different results concerning sites of obstruction. Additionally, any surgery to one part of the pharynx seems to influence the other parts of the pharynx in caudal and cranial directions. A literature theory dominates that the pharynx between the nasopharynx and lower hypopharynx acts like several Starling mechanism in series, in which are influences the other. Whether more complicated pressure measurements emphasizing the role of sleep stages and pharyngeal muscle activities could improve the surgical outcome of UPPP is the subject of present investigations. In any case the technical equipment and time consumption of the measurements required will probably disqualify the method for routine use.

56 patients with habitual snoring (n = 43) or with complicated snoring accompanied by sleep apnea syndrome (n = 13) under went uvulopalatopharyngoplasty. The patients were observed for a period of 2 to 84 months (average: 20,8 months). Postoperatively, 80 % showed a disappearance or great reduction of snoring intensity. Other symptoms of obstructive sleep apnea syndrome such as apneas, tiredness during the day and deterioration of sleep quality also improved markedly. In ten out of 13 patients with a demonstrated sleep apnea syndrome, the apneas disappeared or became noticeably reduced (in seven patients shown by means of a polysomnographic check-up). Two patients developed velopharyngeal stenosis, which was subsequently corrected. Other operative side effects were temporary (from days to weeks) and only minor (transient speaking problems, nasal regurgitation, rhinopharyngitis sicca, taste disturbances).

The clinical picture of the obstructive sleep apnea syndrome is caused by a multifactorial etiology. Therefore a lot of different conservative as well as surgical therapeutic approaches are discussed. In approximately 40% of the patients an obstruction of the pharyngeal airway is combined with an abnormal sagittal morphology of the skull. In these cases a simultaneous maxillomandibular advancement by at least 10 mm seems to be a causal therapy, leading to an enlargement of the pharyngeal airways. The current therapeutic results are roughly stable up to a period of approximately 3 years. Requirement of this therapy is the exclusion and/or the prior therapy of an extreme obesity, which can favour the manifestation of an obstructive sleep apnea syndrome.

We have developed a new surgical approach, called functional palatoraphy. This procedure preserves the posterior border of the soft palate and allows a controlled repair of the soft palate. It is routinely combined with a chin osteotomy. In selected cases this procedure is an alternative to other surgical methods.

Mental capacity, assessed by several anamnestic questions, was improved by adenoidectomy in 46 children with adenoid vegetations and was influenced by hypoxic episodes during sleep. Hypoxic desaturations during sleep can be predicted by 5 anamnestic and clinical parameters (specificity 70%, sensitivity 85%).

10 patients with obstructive sleep apnea syndrome (OSAS) have been treated with the new surgical procedure functional palatoraphy and modified genioplasty. 5 months after surgery 7 patients with an apnea hypopnea index under 10 were cured. Three therapy refractory patients were all overweight with a body mass index of more than 29 kg/m2. Excessively overweight patients should therefore not be operated. Following the selection criteria we introduced an effective new treatment method for OSAS.

The efficacy of uvulopharyngopalatoplasty (UPPP) in treating obstructive snoring has been reported from many centers. The reduction of uvula and soft palate may result in palatal incompetence. We examined 23 patients undergoing UPPP pre- and postoperatively and found a slight preoperative hypernasality in three patients. None of our patients had problems with swallowing. During the first week postoperatively, most of the patient had hypernasality and noted a nasal escape of liquids. Three to four months after surgery, three patients still had problems swallowing. All 21 patients seen during the last follow-up examination had a nasal escape of air detected by auscultation in at least one of the tests. Two patients had an audible hypernasality. Two patients could not pronounce the letters any more. More than one year after surgery, palatal incompetence was no longer detectable.

Patients with heart failure are known to demonstrate periodic respiration during sleep. The mechanism behind periodic respiration is thought to be related to left heart enlargement causing an increased transit time between lung and chemoreceptors leading to an oscillation of the feed back loop controlling respiration. Additionally hyperventilation was shown to play an important role. We report of an 18 year old patient with idiopathic dilated cardiomyopathy (left atrial 52 mm, left ventricular end diastolic diameter 69 mm). Polysomnography revealed prolonged transit time and periodic respiration with impaired sleep. Hypocapnia and hyperventilation was demonstrated. Following successful cardiac transplantation periodic respiration was absent and transit time was normal. There was no hypocapnia or hyperventilation. Hypercapnic ventilatory response did no change. These findings support the model of an oscillation of the feed back loop controlling respiration as the main pathomechanism behind periodic respiration.

The otolaryngologist is increasingly involved in the evaluation and management of sleep-related respiratory disorders. Main symptoms of intermittent obstruction in adults and children are snoring and stridulous breathing. Important factors causing pharyngeal obstruction are functional and structural narrowings in the upper airways leading to increased upstream resistance. The ENT's examination has two principal aims: 1. habitual snoring must be separated from an obstructive sleep-apnea syndrome (OSAS), as the later is associated with cardiovascular diseases and an increased mortality; 2. a functional or structural cause of the obstruction must be sought. Flexible nasopharyngoscopy is a valuable diagnostic tool to determine the nature of obstruction. OSAS patients need a differentiated evaluation in a sleep laboratory, and an attempt of therapy with continuous positive airway pressure (CPAP) should be undertaken in most of these cases. Today the otolaryngologist is equipped with a whole range of conservative and surgical therapeutic possibilities. The introduction of compact lasers as well as the endoscopic/microscopic endonasal surgery have revolutionized surgical treatment in patients with habitual snoring and OSAS. In contrast to adults, OSAS in children has still received poor attention and leads often to impaired thriving. Most frequently, hypertrophied tonsils are present, and tonsillectomy eliminates obstruction in nearly all of these cases.

Surgical treatment of obstructive sleep apnea with abolition of obstructive apneas and hypopneas is possible by maxillomandibular advancement as our own results in 24 patients show. Maxilla and mandible must be advanced at least about 10 mm to secure success. Indication for maxillomandibular advancement should be restricted to patients with certain craniofacial disorders, which are of retrognathic dolichofacial type combined with pharyngeal narrowing. Before considering surgical treatment other possible contributing factors as for instance obesity should be eliminated, the more as nCPAP-therapy constitutes an effective conservative method. Despite our unchanged success rate after 1 year further polysomnographic follow-up control is essential to see what happens 5, 10 or 20 years after maxillomandibular advancement.

Uvulo-palato-pharyngo-plastic is one possibility for treatment of obstructive sleep-apnea. We examined in a prospective study design 36 patients, suffering from polysomnographically ensured obstructive sleep-apnea-syndrome, who were undergone uvulo-palato-pharyngo-plastic. We analysed pre- und postoperative polysomnographic data. Most of patients demonstrated a decrease of amount of apneas, duration of apneas and an increase of minimal oxygen-desaturation. Patients who had high amounts of apneas (AI > 40/h) or who had a Broca-index > 140 p.c. gained not as much from surgical treatment as other patients did.

The amount of different clinically available lasers is increasing. The ENT surgeon can therefore use the best laser for the planned operation. As the resources of the hospital do not increase with the laser technology, a decision has to be made whether in addition to the universal CO2-laser other types must be acquired and which type is best. This paper presents the characteristics and typical tissue interactions of several lasers for the area of the soft palate. Typical operative examples are shown, e.g. partial resection of the soft palate in patients with bronchopathy and sleep apnoea syndrome, tonsillectomy, tonsillotomy and adenotomy in adults.

Polysomnography measurements were performed before and 8 weeks after surgery (UPPP). Most of the cases showed a decrease in the number and duration of apnoea phases. Oxygen saturation increases.

At the Philipps-University Marburg 14 patients with obstructive sleep apnoea syndrome (OSAS) have so far been successfully treated by surgical maxillo-mandibular advancement. These results clearly indicate that surgical treatment and cure of OSAS by maxillo-mandibular osteotomy is possible in case of an appropriate indication.

Approximately 20% of the population snore. Snoring is caused by a vibration of oropharyngeal soft tissues during air flow. The anatomical origin of snoring can be the soft palate with a hyperplastic uvula or the region of the base of tongue. An uvulopalatopharyngoplasty (UPPP) as a mode of surgical treatment is only appropriate in the first case. A patient can be considered to be suffering from sleep apnea syndrome if snoring is associated with a temporary complete obstruction of the upper airway with a subsequent decrease in oxygen saturation. In this case continuous positive airway pressure (CPAP) therapy can be beneficial; however, the role of surgery is confined to those operations providing unimpaired nasal air flow. Following extensive preoperative diagnostics, including sleep monitoring with the MESAM-IV-system, 68 patients with palatal snoring underwent surgery. 46 could be examined 6 to 8 months postoperatively: In 41 patients snoring disappeared completely or was reduced to a few occasional episodes. 5 patients continued to snore after the UPPP. These patients were obese at the time of surgery and a preoperative attempt to lose weight was only partially successful. Although we identified the soft palate as the probable cause of snoring by fiberoptic examination, especially the overweight patients bear the risk of additional narrow segments in the region of the base of the tongue. The appropriate weight loss is therefore a fundamental prerequisite for successful treatment. 5 patients with sleep apnea syndrome combined with nasal obstruction underwent septum, turbinate and sinus surgery to create unobstructed nasal airflow. The following CPAP treatment was of great benefit to them.(ABSTRACT TRUNCATED AT 250 WORDS)

The actual therapy of choice for the common obstructive sleep-apnea syndrome is the application of continuous positive airway pressure (CPAP) via a nose-mask. This ventilation by positive pressure is explained in some detail. Mechanical ventilation for treatment of nocturnal respiratory failure in outpatients of various etiologies is covered in the companion paper by J. C. Chevrolet. Treatment of sleep disorders due to other pulmonary diseases such as bronchial asthma and others require treatment of the underlying disorder.

Unlabelled: Cephalometry: Morphologic alterations can be found in a great deal of patients with OSAS, predisposing to the rise of sleep apnea. In addition to preexisting investigations we developed a cephalometric analysis to judge these alterations in patients with OSAS. Comparing 160 patients to healthy people pharyngeal obstructions could be found in more than one third of the patients, usually combined with a retrognathic dolichofacial morphology., Surgical Procedure: As successful treatment of our own patients shows, curing of obstructive sleep apnea is possible in respect of these cephalometric alterations. The basis of surgical treatment consists of surgical advancement of the mandible by sagittal split osteotomy and advancement of the maxilla by Le Fort I-osteotomy. Advancement surgery must be done in consideration of the morphologic alterations mentioned above. Additionally secondary procedures can be taken into account as genioplasty, soft-tissue-corrections or corrections of the upper airways.

The article reports on the results obtained by uvulopalatopharyngoplastic surgery (= UPPPS) in 31 patients suffering from obstructive sleep apnoea syndrome (= OSAS) and in 9 patients with habitual or obstructive snoring. All patients were subjected to thorough preoperative examination including rhinometry, nasopharyngeal video-endoscopy, radiocephalometry and polysomnography. In 8 out of 9 (89%) of the habitually snoring patients and in 17 of 31 (55%) of OSAS patients, surgery was successful. In these patients, a postoperative respiratory disturbance index (RDI) of less than 10 was recorded, whereas in 4 patients (13%) the postoperative RDI was between 10 and 15. Ten patients did not respond satisfactorily to UPPPS (32%). RDI was postoperatively still above 15. Analysis of patient data shows that almost all habitually snoring patients and the OSAS patients with slight overweight and low to medium apnoea index were successfully treated with UPPPS. In accordance with these results a treatment concept has been drawn up for OSAS patients that takes stock of all the possibilities and limitations of available conservative and surgical treatment methods.

200 of 300 patients who were operated on because of strident snoring or of a sleep apnoea syndrom were examined in a follow-up study. In 93.5% turbinectomy was performed simultaneously, in 50% septum plasty, and in 9.5% endonasal revision of the sinus. On Improvement of snoring was noted in 81.5% of the patients, cessation or improvement of the apnoea in 83%. Daily tiredness was reduced in 65% of the operated patients, and partner problems were solved in 78%. Recommendation for operation was given in 75.5% of the cases. Due postoperative complaints and the lack of results, however, 21.5% could not, and 3% restricted their recommendation to others to undergo surgery. The satisfactory results and the high acceptance of the operation confirmed uvulopalatopharyngoplasty as a solid and efficient operation to help patients suffering from an obstructive sleep apnoea syndrome. If the operation is performed carefully and cautiously, there is no fear of negative consequences such as rhinophonia and difficulties in swallowing.

Knowledge of the connection between habitual snoring diseases and obstructive sleep apnoea has stimulated research into sleep disturbance in patients at high risk of cardiovascular disease. Any disturbance of nasal ventilation leads to a higher resistance to breathing and may cause cardiovascular complications in the long run. Anatomical and functional conditions that lead to intermittent incomplete blockage or complete occlusion of the upper respiratory tract must be detected and surgically eliminated, if possible. Surgical procedures for treating snoring and obstructive sleep apnoea may be successful and fill the gap between conservative treatment and continuous nasal positive airway pressure therapy. Our experience in 24 patients in presented.

Pulmonary hypertension without any cardiovascular malformation was diagnosed by heart catheterization in a 4 year old girl with trisomy 21. A suspected obstructive sleep apnea syndrome was confirmed by polysomnography which revealed numerous obstructive apneas and hypopneas (apnea-index 23/h) with marked oxygen desaturation and a disturbed sleep pattern. Three months after adenotonsillectomy the mother reported her daughter having a quiet sleep without snoring. Polysomnography did not show any apnea nor any oxygen desaturation below 90%. A decrease of the pulmonary artery pressure was documented. Facial dysmorphias and muscle hypotonia predispose patients with trisomy 21 to obstructive sleep apnea, especially if hypertrophy of tonsills and adenoids coexist. Frequent arousals and hypoxia during sleep can result in failure to thrive and pulmonary hypertension. These consequences can be prevented by early diagnosis and treatment.

This study contributes to the evaluation of the question whether patients with obstructive sleep apnea syndrome might benefit from maxillary surgery. Changes in nasopharyngeal and hypopharyngeal airway spaces of 13 non-apneic patients following maxillary advancement and/or impaction osteotomies were studied retrospectively by cephalometric analysis. The data suggest a long-term increase in both nasopharyngeal airway space and unexpected, in hypopharyngeal airway space which remained stable over time. The clinical implications are discussed in view of previous studies which suggest or recommend orthognathic surgery as a treatment modality in selected patients with obstructive sleep apnea syndrome.

The only surgical means available up to now for treating obstructive sleep apnea syndrome (OSAS) consisted in uvulopalatopharyngoplasty (UPPP), which failed to produce satisfactory results. The ultima ratio frequently resorted to was tracheotomy with all its medical and social drawbacks. Complete advancement of the maxillomandibular complex opens up new avenues for the treatment of upper airways obstruction. The present report is on 13 patients operated for polysomnographically established OSA. The maxillomandibular complex was brought as far forward as possible and esthetically justifiable. This operation was occasionally combined with other procedures to enhance upper airways function, such as conchotomy, palatopharyngoplasty, chin graft and reduction of tongue size. In 85% of the cases the apnea and hypopnea index (RDI) could be lowered to below 10 per hour sleep, i.e. these patients were cured.

This is a report on 30 cases of innominate artery compression of the trachea and its operative correction by an aorto-truncopexy. Tracheoscopy is the most important examination for arriving at the diagnosis. Magnetic resonance imaging (MRI), which offers representative pictures of many moments of expiration and inspiration, shows the anatomic relationship between the innominate artery, the aortic arch and the trachea, also demonstrating the extent of the tracheal compression. Surgical treatment is indicated if narrowing of the lumen of the trachea is greater than 70%. By fixing the aortic arch and the proximal innominate artery at the back of the sternum the trachea is relieved of its compression. In 30 children there was no unsuccessful operation, and none of them died.

The clinical pattern of signs and symptoms of respiratory complications due to flaccid trachea has been analysed in 83 children treated in our hospital between 1983 and 1988 for tracheo-oesophageal malformations. These signs and symptoms are classified according to endoscopic findings, and are thus arranged according to various degrees of severity. Of the surviving children who were followed up and who were suffering from oesophageal atresia Vogt III B, only 5 of 57 were without a pointer towards flaccid trachea, whereas in oesophageal atresia Vogt II there were two of three. The two children with an isolated tracheo-oesophageal fistula showed abnormal findings both clinically and via endoscopy. 16 of the 20 children with very severely pronounced flaccid trachea--defined by the occurrence of life-threating apnoeas and an endoscopically identifiable tracheal collapse of more than two-thirds of the lumen--were subjected to surgery via aortosternopexy. A marked and identifiable improvement was obtained in 15 cases. Complications caused by surgery consisted of temporary phrenicus lesions in two cases.

Sleep-related closure of the upper airways is the key feature of the obstructive sleep apnoea syndrome (OSAS). Excessive daytime sleepiness and loud snoring are the major signs. It is not possible to differentiate patients with the single complaint of habitual snoring from patients with sleep apnoea by their history alone; polysomnography is a mandatory procedure. Recently, uvulopalatopharyngoplasty (UPPP) has been introduced as a surgical procedure to treat OSAS and excessive snoring. This paper presents the results of UPPP in eleven patients evaluated by means of postoperative polysomnography.

32 patients with habitual snoring and 2 patients with obstructive sleep apnea syndrome underwent nasal and/or palatopharyngeal surgery. 12 patients with combined nasal septoplasty, submucous resection of the inferior turbinate bones and palatopharyngoplasty gained total relief from snoring. The same result was achieved in 10 children with removal of extremes of tonsillar and adenoid enlargement. From 7 patients with nasal surgery alone 4 experienced total improvement in the snoring, 3 perceived no long-term relief. 3 adults with PPP alone gained some change in their snoring. Uvulectomy in 2 adults had no influence on the snoring situation.

Laryngo-tracheo-bronchoscopy on a 2 year old boy with the sleep apnea syndrome showed no anatomic abnormalities and no signs of upper airway obstruction. After tonsillectomy the infant revealed an improvement in sleep pattern, and 1 1/2 years later, the syndrome has been relieved completely. In our opinion, the sleep apnea syndrome is an indication for tonsillectomy.

In 17 illustrations, a modification of Fujita's technique of UPPP is presented. This operation consists of excising redundant velar tissues from the free margin of the soft palate, tonsillar pillars, and uvula without reducing the muscles of the velum. In addition, the uvula muscle is almost completely preserved. Seventy patients, with habitual snoring or with obstructive sleep apnea syndrome, who underwent this surgery were followed-up from six to 24 months and did not show any palatal insufficiency with air and liquid escape through the nose. Additional remarks are made concerning the difficulties encountered during intubation of 60 percent of patients with chronic rhonchopathy.